The Impending Catastrophe: A Resource Book On The Emerging HIV/AIDS Epidemic in South Africa (Executive Summary)

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Executive Summary

South Africa is certain to experience severe consequences arising from its AIDS epidemic. Over 3.5 million people are currently estimated to be HIV infected, and this number is projected to more than double over the next decade – unless major behavioral changes are adequately promoted and realized. Younger people are most severely affected by the disease with around 60% of all adults who acquire HIV becoming infected before they turn 25.

Young women are particularly vulnerable. They are at greater risk of infection due to biological, social and economic factors; they are also more vulnerable to the various effects of the epidemic. While not fully representative, a recent KwaZulu-Natal voluntary survey of university students demonstrated infection rates of 26% in women and 12% in men, aged 20 to 24, and 36% in women and 23% in men, aged 25 to 29. These data further emphasize the need for priority prevention programmes for young people and women.

Orphans are perhaps the most tragic and enduring legacy of the HIV/AIDS epidemic. By 2005 there are expected to be around 800 000 orphans (under age 15). This figure will rise to more than 1.95 million in 2010. Models of providing support for these vulnerable children and their communities urgently need to be explored because traditional coping mechanisms are likely to break down.

The sharpest economic effect of the South African epidemic will probably be on wealth distribution rather than on the size of the economy as a whole. In the field of human and social development, however, the consequences are expected to be much more profound. Increased illness and deaths, and reduced life expectancy, will clearly compromise development objectives, while the survival of poor households will be made more difficult.

Increasingly, HIV/AIDS is expected to be a major determinant of the ability of households to extricate themselves from longstanding poverty. Virtually no research has been done on the impact of HIV at household level, and how government might most effectively target relief. Such relief is urgently required.

Also a priority is the provision of good information to people with HIV/AIDS, so that they can gain access to available support and allocate their resources in a way that reduces the effects of the disease on themselves and their households. There is also a need for efficient grant or other support systems, not only for the HIV-disabled, but also for the elderly and others involved in child support to relieve household economic hardships. It is important that available resources are targeted at the most vulnerable households, communities and sub-groups, and that the resources are directed towards supporting all affected people, not just those who are infected or ill. Every effort should also be made to reinforce traditional and new community- and family-based coping mechanisms.

The HIV/AIDS epidemic far outweighs any other threat to the health and well being of South African employees. AIDS deaths will soon exceed all other causes of death put together among the South African workforce. Although data on workforce infection levels is very limited, the number of employees lost to AIDS over the next ten years could be the equivalent of around 40 to 50% of the current workforce in some South African companies. Accelerated skills development in both young and working-age populations will be critical in containing the impact of the HIV/AIDS epidemic on the economy.

However, the high mortality rate among current and future employees implies that skills development without effective HIV/AIDS prevention might be a poor investment. South Africa already faces enormous challenges in human development owing to training backlogs, inherited inequities and inefficiencies in the education system. Substantial investment in preventing HIV transmission in trained workers is therefore warranted. Businesses have a key role to play in the area of prevention and also in reducing denial and stigma. The most significant costs of the epidemic for most companies are likely to be indirect, including increased absenteeism due to illness or funeral attendance, lost skills, training and recruitment costs, and reduced work performance and lower productivity.

One of the most obvious economic consequences of the HIV/AIDS epidemic is the need for increased resources to care for the sick and dying. Both public and private health sectors will be seriously affected. Projected expenditure will almost certainly not be sustainable, given public and private sector affordability constraints. This implies that some rationing will have to occur to reconcile needs with available resources. It is possible that HIV-related disease sufferers will experience a greater degree of rationing than other health service users. The challenge for both public and private sectors is to shift to more cost-effective modes of therapy for HIV/AIDS sufferers, rather than resorting to irrational or even discriminatory exclusion from services. These cost effective modes will need to include a re-orientation towards lower cost hospice type care instead of acute hospitalization, as well as consistent and substantial support to community-based care initiatives. These interventions have not yet received much attention from the public sector.

At the primary care level, widespread secondary prevention programmes, such as TB and pneumonia prophylaxis, should be urgently implemented. South Africa’s TB control programme is already over-extended and new strategies to respond to the increased burden of TB cases are urgently required. Widespread use of anti-retroviral therapy for AIDS-sick people does not appear at this stage to offer a realistic solution. Even in the relatively wealthy private sector, large price reductions would be required before net savings in health care costs could be expected. AIDS activists and international agencies would spend their time more effectively by advocating delivery of basic programmes of care, and continue efforts to promote anti-retrovirals to prevent mother-to-child transmissions.

With no prospect of an AIDS vaccine in the foreseeable future, HIV prevention requires sustained promotion of healthier and safer sexual behaviour. Achieving this within a context of many situations and cultures is a complex task, requiring integrated inter-sectoral approaches implemented at all levels of society. Prevention programmes must create a social consciousness and environment that leads to appropriate behavioral change. This requires active efforts to reduce stigma and discrimination around HIV/AIDS. While the vast majority of those at high risk in sexually active age groups have already been infected, considerable opportunity still exists to prevent new HIV infections amongst succeeding waves of teenagers. This group presents important opportunities for targeted interventions.